Wesley Tomich was trapped under a metal frame and asphyxiated. Photo: Supplied / Givealittle
A major fertiliser company was told 80 times in a single report that its conveyor belt safety standards were not up to scratch, months before a worker died on one of its huge belts.
Wesley Tomich fell on to badly guarded belt at Ballance Agri-Nutrients' plant in Mt Maunganui in July 2023.
A WorkSafe report - newly released to RNZ - shows an investigation began within hours, but that the investigator did not interview the company's management for five months.
It summed up a report engineering firm Beca gave Ballance in 2022.
"Throughout the document, non-compliant guarding is mentioned 80 times in total," said the investigation.
"There are multiple risks identified with multiple proposed controls."
'Crash number 4'
The prosecution over the death resulted in a $420,000 fine in March this year.
The courts and coroner heard that Ballance was warned by independent experts in 2015, and again in 2022, that its huge conveyor belts - up to 300m long - needed to be guarded and emergency stops put in closer to hand.
Tomich, 37, slipped and fell while stepping over a moving belt while workers were cleaning up fallen fertiliser. He was trapped under a metal frame and asphyxiated.
"I saw Wesley step across the belt on infeed 4," a colleague told the Worksafe investigator who first got to the plant on 27 July, in the report released under the Official Information Act.
"Everyone knows this is dangerous and shouldn't be done. When he stepped back over infeed 4 he slipped.
"Wesley said 'crash number 4' which means to stop it. He was too close and there was no time to react."
Official standards required the belts to have guards but the Mount plant's were "intermittent and not secured".
"Relying solely on SOP's [safe operating procedures] is not recommended, as people may not consistently adhere to them, especially when under time pressures."
WorkSafe had 'no cause to doubt'
WorkSafe's investigator interviewed Ballance management in December, following the July 2023 death.
"Five months is not an unusual point in an investigation for a formal interview," the agency told RNZ.
It had to gather expert advice and review extensive documentation first.
On the same day they did the interview, they signed off a final copy of their report.
"While it is uncommon for a report to be finalised on the day of a formal interview, it can happen," WorkSafe said.
"Investigation report writing is a cumulative process that isn't solely dependent on one interview."
The investigator recorded what the company's bosses told them in the interview, in six lines of a 30-page report.
"Ballance was working towards addressing guarding issues and were aware the conveyor system required guarding improvements to comply with the relevant industry standards and had made improvements across Ballance other sites and departments," was one line.
"The despatch area [where Tomich died] was last the department to be addressed."
The investigator also wrote that the company knew it needed to fix the emergency stops, but that required electrical upgrades as "part of a larger and complex project" of five years' duration.
They did not need to verify this further, given all the previous fact-finding, WorkSafe told RNZ.
"Given the totality of information, WorkSafe had no cause to doubt the comments made by Ballance at interview and had no need to seek further verification."
It added: "WorkSafe did not visit any other Ballance site as part of this investigation, which focussed entirely on the death of Wesley Tomich."
'Systems failure'
WorkSafe launched a successful prosecution of the company on one health and safety charge.
Ballance's lawyer told the court December that the expert reports in 2015 and 2022 did not identify specific high risks over cleaning around the conveyor belts.
They pointed to the company's long trading history and safety record, and argued this was a "systems failure", not a breach of industry standards.
But by early 2025, Tomich's parents and sisters were asking the coroner for the firm's directors and management to face more questions.
The coroner rejected that, saying Worksafe's investigation was sufficient.
Past injuries
WorkSafe had twice before investigated Ballance on unspecified dates over badly guarded conveyor belts and hand injuries, the December 2023 report said.
It issued three Improvement Notices, but there was no mention of any follow-up.
The company had 370 interactions with the agency across its various sites, and 52 compliance actions, by late 2023.
Law changes sparked by the 2010 Pike River mine disaster were designed to make it easier to prosecute directors and company executives, but WorkSafe has struggled to do this, such as over the Whakaari White Island deaths.
Workplace Safety Minister Brooke van Velden said in April she would change the law so company directors and boards did not bear responsibility for the day-to-day managing of health and safety risks.
'In the danger zone'
Following Tomich's death, Ballance spent a lot on upgrades, the coroner and court said.
It "appear [sic] genuinely remorseful and have made offer of payment to the family", WorkSafe's investigator wrote.
Senior WorkSafe managers signed off the December 2023 report, calling it a "swift but thorough investigation" and a "good detailed investigation into a tragic accident".
Workers at the Mount Maunganui plant had recounted shovelling fallen fertiliser on to a moving conveyor belt during cleaning.
They should have had to shut it down and lock it off, but often did not.
"Ballance safe operating procedure (SOP) talks to allowing workers to be in the danger zone... of the conveyor system while it is energised. Specifically stating that 'you may now shovel product on floor onto moving conveyor belt'."
One worker said: "We are not meant to cross the belts. But sometimes do just to avoid having to walk to the end of the belt, I guess out of convenience."
It was a 60m walk from the accident site to a gantry across the belts.
Ballance was unable to confirm to WorkSafe if Tomich was trained in cleaning the conveyor belts, but its own records suggested he was not.
The electrics and emergency stops were set up in a way that ''goes against the principle of allowing those at risk to have direct control over their safety", the investigator reported.
'No genuine and reasonable attempt'
The WorkSafe investigator concluded in the final report: "Ballance had made no genuine and reasonable attempt to put in place an appropriate system of work or have in place a form of guarding for the conveyor system to prevent injury arising out of events that were reasonably readily foreseeable."
Ballance had revenues this financial year of $965m, up four percent.
RNZ has asked the company why it did not fix the belts after the 2022 Beca report.
It responded with a short statement it first issued in March 2025 when the court ruling came out, stating that Tomich was lost in a sudden and tragic accident, and everyone who knew him was "immensely impacted". It said it had put in measures and training and was "committed to recognising the failures and learning from this tragedy wherever we can".
A district court judge in a ruling in March said the cost of safeguarding the belts for cleaning was "not grossly disproportionate when weighed against the likelihood and risk of harm".
He found the primary failure was letting workers clean around running belts.
Facing a maximum fine of $1.5m, Ballance got discounts for remorse and an early guilty plea, from a starting point fine of $700,000.
Van Velden said in July she was "simplifying machine guarding rules" under wide-ranging workplace safety reforms.
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